Standard Agent Application Information Sheet

1 M1086- Standard (R-2/2015) Standard Agent Application Information SheetThis page is an instructional page that will assist you in completing the Application for an Agent Agreement or General Agent Agreement,as applicable with Allianz contracting and appointment process does not begin until the following requirements are received. Incomplete Information willdelay the contracting and appointment process. Complete, sign and date the Agent Application and the consent to Background Investigation form. Provide verification of completed AML training. (If using LIMRA there will be an automatic feed to Allianz Life Insurance ) Provide a copy of your E & O coverage certificate with a minimum $1 million in coverage Provide continuing education certificates in states that require this training. Complete Allianz Product training prior to solicitation. Read and Agree to the Allianz Life Code of Best Practices.

2 Provide the completed forms to your FMO for submission to Allianz; FMO's, please either upload the completed forms or email them to we receive the Agent Application and proper authorization forms, we will commence a background check. To be eligible for anAgent Agreementor General Agent Agreement as applicable with Allianz Life you must meet the Allianz requirements, state and federallaws and regulations. Allianz may request that you clear outstanding items with a credit reporting agency or state regulatory body prior Life considers various factors in determining whether or not to accept this Application and enter an Agent agreement with of the factors considered are listed below. Any single factor may be a disqualifying factor:Financial Debt and Public Records No credit report available Bankruptcy within the past three years (by discharged date) Any of the following individually, or any of the following that combine to exceed $15,000: Collections or charged off debt in excess of $10,000 Liens/judgments in excess of $10,000 Foreclosures/civil suits in excess of $10,000 Vector(s) in excess of $10,000 Criminal convictions / civil actions Misdemeanors.

3 Reviewed case by case Felonies, automatic decline Litigation or arbitration in the last three years in which you and Allianz Life have/had any opposing claims will be an automatic decline Insurance license/appointment actions State license revocation/suspension within past five years State license restriction/fines within past five yearsFINRA or other state or federal agency Customer disputes, disciplinary and regulatory events; reviewed case by case FINRA bar is an automatic declineIf, after our review, we accept this Application , you will receive a Standard Agent Agreement or General Agent Agreement, asapplicable. Your individual state appointment(s) with Allianz Life will be effective immediately in the states that require anappointment upon contracting and if you are licensed in states that have regulations that allow us to appoint you upon receipt ofbusiness, we will appoint you in that state as business is : PA and MT require appointment prior to solicitationAllianz Life Insurance Company of North AmericaPage 1 of 6We understand that, as an Allianz Life appointed financialprofessional, you share our desire to build long-standingrelationships of trust with the clients who purchase Allianz Life products.

4 Together we help clients feel confident that they are buying a product they understand and believe is right for their situation. When marketing Allianz Life products, we are committed to the following best practices:SuitabilityThe recommendation of a financial solution must be based on theclient s individual needs and financial objectives: Record and file the Information you gather from the client, aswell as your recommendations. Thoroughly understand the product you are describing and howit serves your client s unique financial situation and objectives,which includes, but is not limited to: An analysis of their income and expenses Understanding their financial goals Assessing their tolerance for riskMore Information : Please refer to the Allianz Life Agent Guide toAnnuity Suitability, the Compliance Guide to Successful Business,and the Suitability eLearning recommended replacement of an existing product must bebased on the replacement product s ability to better suit the client scurrent financial situation and goals.

5 Fully explain the benefits and costs of replacing the client sexisting policy. Provide an impartial assessment of the comparative benefits andrestrictions of both policies. Maintain accurate records that reflect the key issues youdiscussed with your client regarding the comparison of bothproducts. This includes, but is not limited to: surrender charges,expenses, guarantees, and historical renewal rates. More Information : Please refer to the Compliance Guide toSuccessful Business and the Replacement eLearning module. DisclosureYour clients need a full, unbiased explanation of their options tomake informed decisions. Provide your clients with full and accurate disclosure about anyAllianz life products you recommend. Although these disclosuresare included with the marketing and sales materials, disclosure isnot just about providing brochures and other documents thatyou hope your clients read. You need to be actively involved,leading a discussion and checking for client understanding.

6 Ensure that your client reviews and signs the appropriatedisclosure documents at the time they purchase an Allianz lifeproduct. More Information : Please refer to the Compliance Guide toSuccessful Business and the Disclosure eLearning Allianz Life PoliciesAllianz Life expects that you understand and comply with all AllianzLife business requirements as outlined in the Agent Guide toAnnuity Suitability, the Compliance Guide to Successful Business,the eLearning modules, and all other Allianz Life agreeing to follow these practices, we can earn and keep thetrust we build with our signing the Agent Application , you agree to adhere to the AllianzLife Code of Best Life Insurance Companyof North AmericaPO Box 59060 Minneapolis, MN of Best PracticesM1086- Standard (R-2/2015)M1086-S tandardPage 2 of 6(R-2/2015)Product Line InformationI would like to sell the following products: Fixed life or annuities variable insurance products (BD must have active selling agreement)The Field Marketing Organization (FMO) that I will be conducting future Fixed Annuitybusiness with is _____FMO#_____.

7 I understand that I will be assigned to the above-referenced FMO hierarchy for Fixed Annuitybusiness Field Marketing Organization (FMO) that I will be conducting future Fixed Lifebusiness with is _____FMO#_____. I understand that I will be assigned to the above-referenced FMO hierarchy for Fixed Lifebusiness Information (please print). If the Agent is a company (partnership or corporation, ) and is applyingas such, a company owner, officer or principal must complete this (as it appears on your resident state license):(FMO Assigned)Annuity Agent #:Life Agent #:Resident address (street, city, state, zip) (No PO Boxes):Business address:Date of birth:Social Security number:Resident county:Work phone number:Home phone number:Cell phone number:Email address:Fax number:FINRA InformationAre you currently or have you ever been FINRA registered? No Ye s RIA IARB roker Dealer Name:_____ CRD#_____Licensing InformationNational Producer Number (NPN): _____ I would like to sell in the following states: _____If you hold a Florida license:*Are you already appointed in Florida with another carrier?

8 No Ye s*If you are requesting a non-resident Florida appointment, please list the counties you intend to sell in. Please note: You need an active appointment in the county prior to you currently have new business pending? Client Name _____ State_____ Date of app _____Policy number (if known)_____ SSN (if known) _____ - _____ - _____Application for Standard Agent AgreementRecruited by Field Marketing OrganizationAllianz Life Insurance Company of North AmericaPO Box 59060 OvernightMinneapolis, MN 55459-00605701 Golden Hills , MN 55416-1297M1086-StandardPage 3 of 6(R-2/2015)Background informationPlease respond to all questions for you personally and any organizationover which you have exercised control. If you answer yes toany questions, you must attacha signed and dated explanation with all relevant Information , including dates and supporting documentssuch as copies of documented payment arrangements for outstanding debt or court records for litigation and criminal charges.

9 ( yes answer response template available)1. Have you or an officer of your company everhad:a. your Insurance license or any professional license, or FINRA registration suspended or revoked? .. Ye s Nob. a regulatory or consumer complaint filed against you with an insurance department, the SEC, a state securities department or FINRA? .. Ye s Noc. any reportable events on your U-4 or U-5 .. Ye s No2. Have you or an officer of your company everbeen chargedwith or convicted of a crime that was aa. felony? .. Ye s Nob. misdemeanor? .. Ye s No 3. Have you or an officer of your company everbeen involved in:a. any litigation .. Ye s No b. bankruptcy .. Ye s No c. litigation or arbitration in which you and Allianz Life had any opposing claims? .. Ye s No4. Do you or an officer of your company currentlyhave a state, federal or other taxing authority tax lien or judgement?

10 Ye s No5. Do you have anydebt collection matters pending against you? .. Ye s No6. Do you have anycharged off debt items? .. Ye s No7. Have you had anyforeclosures within the last three years .. Ye s No8. Do you or an officer of your company have any outstanding debt(s) with any insurance marketing organization, insurance company(ies), or broker/dealer? .. Ye s No9. If you are an individual, are you an employee of Allianz Life or one of Allianz Life s subsidiaries? .. Ye s No10. Are any immediate family members currently contracted with Allianz Life? .. Ye s No11. State/s and counties of residence and counties of work for the last ten years: Address (street, city, state, zip) Explanation for yes answered questions (use additional Sheet if necessary)Background Question # Action: Date of Action: Reason: Explanation: Resolution: Signature: Date:M1086-StandardPage 4 of 6(R-2/2015)Authorization Agreement for Automatic DepositI hereby authorize the Allianz Life companies listed in this Application and the financial institution named below to initiate credit entries to myaccount and to reverse any entries made in error.